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Related Topics
Points of ViewReview - Points of View
Stories of Psychopathology
by James E. Mitchell
Brunner-Routledge, 2000
Review by Lloyd A. Wells, M.D., Ph.D.
Dec 16th 2000 (Volume 4, Issue 50)

Dr. Mitchell has written this short book for students who are learning about descriptive psychopathology: medical students, residents in psychiatry, psychology students and post-doctoral fellows, social work and nursing students, and other students whose work intersects with the lives and problems of psychiatric patients. My initial reaction, as I began to read the book, was that the chapters were too short and held too little information for these students. As I read on, I changed my mind completely.

Basically, the format of the book is a tour - though fortunately not a comprehensive tour - of the DSM-IV. Each chapter is devoted to a specific disorder, has a brief introduction, lists the current diagnostic criteria for the disorder, then has one or more "stories", followed by a brief discussion, a few questions for further reflection, and a short list of references.

The introductions are very brief and generally get right to the central issues of the diagnostic category. The criteria are - the criteria. The "stories" then put the category in some perspective. They are told from the point of view of the patient and usually someone else - a friend, a spouse, a professional trying to work with the patient. Although these stories are simulated, one can see readily that most are based in part of true and memorable clinical encounters. Mitchell makes some of these patients come alive in these very brief vignettes, and they beautifully illustrate the way the criteria "look" in life as well as the experience of the disorder for both the patient and for those around her. The discussions are often intriguing and ask important questions that seasoned mental health professionals often have stopped asking - to their patients' detriment. The references are few but outstanding for any student wishing to learn more about the disorders or their effects.

My reaction to this book is extremely positive. Rather than inviting students and trainees to memorize a set of criteria, it implicitly makes the point that it is real people who "meet" these rather arbitrary criteria - a truism, perhaps, but one which is often lost on some trainees. As one who works hard to write case vignettes, I know how difficult it is to do this well: Mitchell succeeds. The "stories" are very brief and are constructed with exquisite care. They are often beautifully written. Some of them are brilliant: those for somatization disorder, bipolar disorder, delirium, bulimia nervosa, anorexia nervosa, antisocial personality disorder and body dysmorphic disorder come to mind immediately. The author occasionally introduces a little self-effacing humor as well, which is most welcome. The questions which are at the end of each chapter lead the reader to think more about the case and her or his personal as well as professional reaction to it.

I have very few negative comments. This is not a text of psychopathology or nosology, and it is not intended to be. People seeking such a text should not buy this book. I thought a few of the "stories" - dissociative identity disorder, schizophrenia, substance dependence, obsessive-compulsive disorder, for example --were not as good as the others. A few of the commentaries are really a little bit too sketchy. And anyone can think of a few favorite references which were left out.

It is a tribute to Dr. Mitchell that he accomplished what he did in 222 pages. This is a wonderful, beautifully written book. He makes his views - implicit throughout the book - explicit at the end: "…I have also attempted to make it abundantly clear that these are not stories about illnesses, but instead stories about people… Are the mentally ill different from us? Not really, if we remember that the woman next door may suffer from depression, that the man behind the counter at the drugstore may have panic attacks, that the son of a friend may suffer from schizophrenia, and that you or I may at some time develop a mental illness. It's not 'them', it's 'us'… It seems paradoxical, that as our knowledge of these conditions and the effectiveness of our treatments increase that the percentage of Americans who have no health insurance or inadequate coverage for mental illnesses continues to grow. What good are treatments if people can't receive them?… I encourage those students of psychopathology who read this work … most importantly, to not forget the humanity of the mentally ill, and to advocate for their acceptance and treatment."

This is a superb book for its designated audience. I think philosophers would enjoy the stories very much. I think that seasoned psychiatrists would enjoy and learn from it.

Lloyd A. Wells is a child and adolescent psychiatrist at the Mayo Clinic in Rochester, Minnesota. He has a particular interest in philosophical issues related to psychiatry and in the logic used in psychiatric discourse.


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